The World Health Organization stated
that less than 1% of the population is affected by Rigid flatfoot which causes
pain and disability that may require surgery. While in the U.S. adult
population between 2 to 23% is affected by flexible flatfoot.(Banwell et al., 2014)

Symptomatic Flatfoot is considered pathological, the hindfoot medial region and the posterior tibial tendon is
where the pain generally occurs, sometimes it may be associated with the tendon
sheath effusion.(Toullec, 2015)

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Painful symptoms accompanying
flexible flatfoot include, a wide distribution of pain and an increase in
fatigue rate in lower limb area, osteoarthritis, achilles tendinopathy and
patellofemoral disorders may appear. Other signs observed include the abnormal
appearance of rearfoot kinematics such as a rearfoot excessive eversion or by
an increase in the eversion range, abnormal kinetics of the foot and ankle such
as joint moments elevated or loading forces abnormal values and change in the
physical function by abnormal timing and activation of muscles or by raising consumption
of energy. These functional consequences are the reason for the symptomatic
flexible flatfoot, and the intervention should target these abnormalities.(Banwell et al., 2014)

In adult acquired ?atfoot, the deformity
is due to arthritic changes, neuromuscular diseases, and traumatic conditions.
While the most common deformity cause remains posterior tibial tendon
dysfunction, many conditions could cause the tendon dysfunction such as rupture
and secondary arthritis which is considered the most severe sequelae, in the U.S.
about 5 million people are affected by this condition.(Abousayed et al., 2016)

Adult acquired flatfoot can be
caused by many conditions such as, ankle degeneration changes that happen in
the tarsometatarsal or talonavicular or both, these degenerations occur
secondary to fractures, inflammatory arthropathy and Osteoarthropathy. the Neuropathic
foot that occur secondary to leprosy, diabetes mellitus and profound peripheral
neuritis. Loss of support at the medial longitudinal arch seen in tibialis
posterior tendon dysfunction or calcaneoanvicular ligament tear. Other
conditions for painful flatfoot may include tarsal coalition. Risk factors
include middle-aged women, hypertension, diabetes mellitus, injecting the area
around the tendon with steroid, and seronegative arthropathies. These factors
are observed in the tibialis posterior tendon insufficiency condition.(Kohls-Gatzoulis et al., 2004)

In flexible flatfoot etiopathology
this study indicated, while the normal medial longitudinal arch of the foot is
formed by the foot bones which are supported by ligaments, tendon and capsular
structures, the medial longitudinal arch is not preserved by the foot muscles.
The electromyographic research resulted in that intrinsic and extrinsic muscles
didn’t help in reinforcing nor preserving the medial longitudinal arch while
assuming a standing position (Basmajian and Stecko, 1963). although during walking the dynamic stabilization of the arch is
maintained by muscles in the both groups, this statement is reinforced by a
study that resulted in that intrinsic muscles of the foot have an important
role in supporting the medial longitudinal arch (Fiolkowski et al., 2003). In the posterior tibial tendon insufficiency flatfoot, it has
been emphasized on the musculature importance, as shown in this study which
resulted that in anatomical structure the most significant structure was the plantar
fascia due to its role in stabilizing the medial arch, along with the talonavicular,
and spring ligaments.(Huang et al., 1993)

In adult, flexible flatfoot may
appear bilateral or unilateral, the main symptoms are pain at arch, heel, and
the foot lateral aspect, these symptoms are aggravated by activities that
include weight bearing such as running, walking, and hiking. Orthotics is
considered to be an early treatment option for this condition(Lee et al., 2005), its designed to stabilize and realign the foot arch, symptoms
relief is a noticeable success in patient.(Chen et al., 2010)

a search of the biomechanical effects of wearing foot orthotics on medial longitudinal
arch in patient with flexible flatfoot from the literature, one study compared
between the effect of short foot exercises and the use of insoles on the medial
arch, in the orthotic group the orthotic
was made to affect the medial arch height (value of 20° and a height of at
least 15 mm) and was standard for all patient. The parameters assessed
was measuring the changes in the height of the medial longitudinal arch, which
resulted in that short foot exercises are more effective and insole 


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